Revenue Generation and Follow-up for a Hand Trauma Program for Emergency Department Patients in an Inner-City Metropolitan Area

Background: Although hand trauma care has proved to be profitable, loss of trauma patients from a system may lead to revenue loss. Our study aimed to (1) elucidate the economic effect of hand trauma programs, (2) quantify the potential fiscal effect of loss of follow-up, and (3) determine factors contributing to leakage of patients from the healthcare system. Methods: Revenue data were retrospectively extracted for all adult hand trauma patients within a multicenter healthcare system from 2014 to 2018. Demographic and encounter factors were analyzed using Wilcoxon rank-sum test for differences in continuous variables, Pearson chi square test for categorical variables, and odds ratios. A follow-up model was created using logistic regression. Results: A total of 56,995 (31% new, 69% established) hand trauma encounters were recorded. Follow-up was markedly affected by many factors, including new vs. established patients. Of the 17,748 new patients, 8638 (48.6%) returned for subsequent care, generating $34M. The patients who did not return may have lost $176M for the system. Conclusions: Many factors lead to loss of follow-up. Understanding these factors can help target efforts to minimize leakage of hand trauma patients. Hand trauma introduces new patients to hospitals, generating notable revenue. Leakage of hand trauma patients has substantial revenue losses.

most prevalent injuries are hand/wrist fractures that occur in 179 of 100,000 trauma patients. 7With this high volume, hand trauma has the potential to create a notable stream of revenue for a hospital system.
While hand trauma programs have previously been fiscally advantageous to hospital systems, 8 hand surgery service lines (not exclusively hand trauma) have demonstrated notable revenue generation for hospital systems because of the prevalence of hand surgery cases and the follow-up opportunities they create. 6,8Studies have been conducted to analyze the continued revenue generated by subsequent visits after orthopaedic trauma presentation. 9Despite the demonstrated financial advantage of orthopaedic trauma and the known volume of hand trauma, the financial benefit of a hand trauma program has not been studied directly.
Many patients presenting with traumatic injuries are new patients who have yet to have an interaction with the healthcare system.A unique opportunity is presented for a patient to establish themselves in the healthcare system after trauma presentation.It is not well-understood whether patients will continue to follow-up with the healthcare system that they initially presented to.Leakage of trauma patients to follow-up may be a challenge within many healthcare specialties, and it can account for a notable loss in revenue and loss of continuity of care for patients. 9Therefore, it is crucial for a healthcare system to be able to identify the patient factors that contribute to a decreased likelihood of following up within the system.
Currently, there is not yet a strong understanding of the patient factors that contribute to loss of follow-up and the downstream financial effect of this forfeiture of revenue.Therefore, the primary purpose of this study was to elucidate the economic effect of hand trauma care and patient loss to follow-up across the orthopaedic hand trauma service for injury/noninjury-related services after initial hand trauma presentation.The secondary purpose was to determine the patient factors that contributed to increasing the likelihood of follow-up within the healthcare system after trauma.Our primary hypothesis is that older, established male patients are more likely to follow up.Our secondary hypothesis is that the greatest revenue would be from rehabilitation services.

Methods
Data were retrospectively collected over 4 years, from January 1, 2014, to December 31, 2018, from a large integrated multicenter academic healthcare system in the Midwest.The population included adult orthopaedic patients presenting for hand trauma evaluation.Any encounter with an ICD-10 code for adult hand trauma presenting to the emergency department was included in this study.All patients were provided with written follow-up care instructions on discharge, and a standardized discussion of follow-up was included in discharge.Interpreters were available at all times and were used during all discussions for any patient with difficulty comprehending English.Follow-up within 6 weeks of hand trauma presentation was recorded.Injury-related care was defined as subsequent care for a hand ICD-10 code.We followed patients for 2 years after the initial presentation to record all subsequent care.
Demographic information including age, sex, race, ethnicity, insurance type (Medicaid Health Maintenance Organization (HMO), Blue Shield or commercial, HAP, Medicaid, Medicare, Medicare Advantage, self-pay, Tricare, and worker's compensation), new vs. established patient status, outside-hospital transfer, hospital admission, intensive care unit admission, hand surgery consultation, and trauma designation of center presented to were analyzed.For patient status, patients whose first interaction with our healthcare system occurred at the presentation of their hand trauma were considered new patients.Established patient status refers to patients who had an interaction with our healthcare system before their hand trauma presentation.
Financial data collected included revenue, cost, and operating margin related to hand trauma presentation and subsequent care.This included both inpatient and outpatient care.Injury-related and injury-unrelated services were included in the analysis.Follow-up was within 24 months after the initial trauma presentation.Lost revenue was calculated by determining the average revenue generated per patient and using that average to extrapolate the potential loss from each patient lost to follow-up.
After these data were collected, Wilcoxon rank-sum test was used to test for differences in continuous variables, Pearson chi square test for categorical variables, and odds ratio for each variable.A follow-up model was created using logistic regression.Results with a P value of , 0.05 were considered statistically significant.received formal hand consultation (4.3%), were admitted to the intensive care unit (0.1%) or hospital (2.3%), or were transferred from an outside system (2.7%).The most common insurance provider was Medicaid HMO (33%).

Return for Follow-Up
We observed a 39.8% follow-up rate for any care within 6 weeks (22,689 of 56,995) and a 68% return for care within 2 years (38,720 of 56,995) (Table 2).15.9% of patients returned specifically for subsequent care related to hand trauma.
For new and established patients (Table 3) returning for hand-related follow-up, there were two patient demographic factors that led to a greater likelihood of follow-up: increasing age (OR 1.01 per year of age, P , 0.001) and 'Hispanic or Latino' (OR 1.25, P , 0.001).Two visit-specific factors that conferred greater follow-up were transfer from an outside system (OR 1.73, P , 0.001) and hand surgery consultation (OR 3.66, P , 0.001).Certain payment factors (worker's comp [OR 1.19, P , 0.001], HAP [OR 1.59, P , 0.001]) resulted in increased follow-up.
When examining only new patients returning for subsequent hand trauma-related care, visit factors leading to increased follow-up included hospital admission, external transfer, and hand surgery consultation (OR 1.48, P = 0.009, OR 1.94, P , 0.001, and OR 4.06, P , 0.001, respectively).Similar visit factors were associated with increased follow-up in new patients returning for hand trauma-unrelated care (Table 4).Payment factors leading to increased followup included only patients using worker's compensation (OR 1.76, P , 0001).

Revenue Generation
For the 9,357 patients (16%) returning for hand trauma-related care, 27,177 encounters were generated, leading to $6.7M in revenue within 2 years of hand trauma presentation (Tables 5 and 6).Potential lost revenue from patients who did not follow-up for injuryrelated care totaled $34.3M.For the 8638 new patients (49%) who received subsequent care, 40,091 encounters were generated.
These totaled over $34M in revenue collection within 2 years of presentation for hand trauma over a 4-year period, averaging $8.5M per year; only $980k was because of the hand trauma (Tables 7 and 8).The 9109 new patients lost to follow-up created a potential revenue loss of over $36M.

Research Article
Stephanie Nulty, MD, MBA, et al

Discussion
This study aimed to determine the economic effect of hand trauma and patient loss to follow-up as well as to identify factors that lead to increased continuity of care after hand trauma presentation.Overall, our study found that there is leakage of a notable percentage of patients from a hand trauma program in a large healthcare system (84%); however, despite this leakage, a hand trauma program continues to provide notable revenue.Relative to our primary hypothesis, we found that older, established patients were more likely to follow-up; however, male patients were not.Pertaining to our second hypothesis regarding revenue potential, we found that 'other surgical services' was the source of the most revenue generated, not rehabilitation services.
In comparison with the study by Flanagan et al, 9 our study was also conducted in a metropolitan area of the Midwest, however, at a multicenter healthcare system as opposed to a single center.This resulted in a higher subject population (56,995 hand trauma encounters compared with 440 orthopaedic trauma encounters).In their study, established patients who were non-White and male were more likely to follow-up after their initial encounter.We also found that established patients were more likely to follow-up when compared with new patients.However, our study found that older patients were more likely to follow-up compared with younger patients.This could possibly be b older patients often having an increased number of comorbidities that could affect their likelihood for follow-up.It is important to recognize these demographic factors that cause loss to follow-up because they could be important opportunities of revenue for an orthopaedic department.
Zelle et al 10 also studied the patient factors associated with loss to follow-up after orthopaedic trauma.Their study included analysis on sex, insur-ance type, and smoking status to determine the effect of these factors on likelihood to follow-up.Notably, while their study showed 73.3% follow-up, our study showed only a 39.8% follow-up rate within 6 weeks of presentation.Furthermore, the authors found that male sex and being uninsured or having government insurance decreased the likelihood of follow-up.We did also note that follow-up decreased with patients who were uninsured/self-paid; however, our study noted decreased follow-up with female sex.In addition, they did not find significance with worker's compensation while we did see a notable increase in follow-up for those patients using worker's compensation.These differences may be attributed to health care in a different city and a different type of patient population.
Similar to Hasan et al, 8 we were able to demonstrate the notable revenue that hand surgery generates.In their study, facility and underlying costs were subtracted from the total revenue generated to determine the net revenue from hand trauma and its subsequent care.In our study, we did not include a cost analysis because revenue is more universal, and therefore, we are unable to discuss profitability.Despite this difference in reported calculation methods, both our study and this study showed notable revenue generated.Dissimilar to our study, the authors included only hand surgeries performed by plastic surgeons; this could limit the profitability of the program because it fails to account for the profit seen by orthopaedic surgeons.
Following the revenue generated by the hand trauma service, the highest revenue-producing specialty was 'other surgical specialties.'This can likely be attributed to the sharing of hand call by plastic surgery in our healthcare system because injury-related subsequent care after hand trauma seen by plastic surgeons would be completed by plastic surgery as well (classified under 'other surgical specialties').This division of the patient

Research Article
Stephanie Nulty, MD, MBA, et al inflow allows hand trauma to be profitable to both orthopaedic and plastic departments, but it is unique to the nature of hand trauma and may have been a notable cause of difference when compared with the study by Flanagan et al 9 in which the highest subsequent revenue generation came from physical medicine and rehabilitation services.This difference could also be because of the multicenter nature of our system and the many private physical/occupational therapy centers in the area.For injury-unrelated subsequent care contributing to 'other surgical specialties,' there are two possible underlying causes in our study: (1).Injuries resulting in hand trauma also required other surgeries that would need subsequent care and/or (2).patients with a positive experience with the hand surgery department came back to the same hospital for subsequent surgeries.The third highest revenue-producing specialty was emergency medicine.The possible causes for this are that the patients were being reinjured or were returning to the emergency department for follow-up care instead of clinics or, because of positive experience in our ED during the initial trauma, they returned for subsequent emergency needs.When we calculated our lost revenue across all systems in the same way done by Flanagan et al, we saw a potential loss of up to $177M.This shows that loss of patients after hand trauma presentation results in notable loss in revenue while also disrupting continuity of care.We subsequently conducted an additional calculation of loss of revenue based on new patients alone.As the hand trauma episode of care represents an opportunity to integrate new patients into the health system, failure to establish subsequent care results in potential loss of revenue from new patients of up to $36M.Therefore, initiatives directed at improving retention rates of new patients would be financially beneficial.This study has several limitations.First, all participants were recruited from a single system, which may limit the generalizability of our findings.However, our study included 56,995 patients from a multicenter system, which can render our results more generalizable.Second, because data were analyzed retrospectively, there were incomplete data points, and some factors were unable to be included because of incomplete information.Third, revenue generated from hand trauma in an orthopaedic encounter is limited because half of hand trauma presentations follow up with the plastic surgery department because of split call coverage.Fourth, hand trauma data were collected only from those presenting to the emergency department; this does not account for hand trauma that presented first to primary care or family medicine clinics.Fifth, we did not have complete data on patient addresses and distance from the center of care; therefore, some may have been from out of state/region and unable to follow up within this healthcare system.Sixth, patients with more medical comorbidities or increased number of injuries may be more likely to follow up because of an increased number of providers initiating follow-up care; however, we did not evaluate this correlation.This is an opportunity for future studies.Finally, of the 56,995 patients included, 39,247 were already established within the healthcare system, and we were unable to attribute follow-up care specifically to hand trauma; we reduced this limitation by calculating the revenue generation for injury-unrelated care using only new patients who returned to the system after hand trauma presentation.
Overall, this study demonstrates the effect that patient demographics have on patient likelihood for follow-up.Increased follow-up was seen with patientspecific characteristics including increasing age and 'Hispanic or Latino'; visit-specific characteristics including transfer from an outside health system, hospital admission, and hand surgery consultation; and payment-specific factors including use of worker's comp and HAP.In addition, hand trauma introduced many patients to the healthcare system who then generated substantial revenue both through

Table 2 .
All Patients Return for Follow-Up With Odds Ratios a n (%); mean (SD).b Pearson chi square test; Wilcoxon rank-sum test.

Table 3 .
All Patients Return for Hand Follow-Up With Odds Ratios

Table 4 .
Analysis of New Patients Returning for Injury-Unrelated Follow-Up With Odds Ratios CI = confidence interval, HMO = Health Maintenance Organization, OR = odds ratio.a n (%); mean (SD).b Pearson chi square test; Wilcoxon rank-sum test; Fisher exact test.

Table 5 .
Charges and Collections for all Subsequent Encounters

Table 6 .
Charges and Collections for all Returning for Injury-Related and Injury-Unrelated Services

Table 7 .
Charges and Collections for New Patients' Subsequent Encounters

Table 8 .
Charges and Collections for New Patients Returning for Injury-Related and Injury-Unrelated Services